psychoeducation and behavioral approaches in cognitive
TRANSCRIPT
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Alireza Atri, MD, PhD
Director, Banner Sun Health Research Institute
Banner Health, AZ
Co-director, Brain Imaging and Fluid Biomarkers Core Arizona Alzheimer’s Disease Center
Lecturer on Neurology
Center for Brain/Mind Medicine Department of Neurology
Brigham and Women’s Hospital, and Harvard Medical School
Psychoeducation and Behavioral Approaches in Cognitive Impairment and Dementia
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Disclosure/conflict of interest – Last 12 months
l I am not/have not been part of any speakers bureau
l Institutional Research Grants or clinical trials: l Novartis (observational cohort study), Global Alzheimer’s Platform, Synexus
(Brain Health Registry, observational cohort study)
l Scientific/Medical/Data Monitoring Advisory Board, Consultation, lectures/CME programs, or Work Groups/Committes: l Alzheimer’s Association, Biogen, Eisai, Grifols, Harvard Medical School
Graduate Continuing Education (HMS CE), Lundbeck, National Institutes of Health (NIH) Roche/Genentech, Suven, Synexus
l Book/Authorship: l Oxford University Press (OUP)
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Effective Multifactorial Management of AD
Early detection, education,
communication, care coordination
& support à Diagnosis &
Disclosure denied is Justice and Care Denied;
and is HARMFUL
Non-Pharmacological:
behavioral strategies; ongoing
monitoring of health & safety and providing support
to patient & caregivers
Pharmacological: reduce potential for harm; slow clinical decline
using approved anti-AD medications;
judicial use of other Rx as needed
Alliance with Patient-Caregiver Dyad
Care for Caregivers à Provide meaningful
benefits to patients, families & caregivers
Atri A. Am J Manag Care. 2011.
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General Considerations – evidence-based medicine and opinion
l ASSESS, EDUCATE, COUNSEL, RE-ASSESS ...
l Assess understanding (knowledge of facts) and appreciation (recognition that facts apply to the person) of the presence and severity of the Cognitive Behavioral Syndrome
l New paradigms for “necessary” supervision and monitoring; establishing habits and compensatory strategies, and communication paradigm (“a new language”)
l Remove deleterious medications; slowly start and maintain combination treatment with ChEI and memantine-add-on; treat exacerbating and comorbid conditions; promote quality sleep, life and health
l Reduce stress – causes confusion and psychomotor slowing and is “toxic” in chronic state – via cortisol and adrenaline in chronic stress response
l Reduce excessive EtOH intake
l Promote restorative sleep (diagnose and treat sleep apnea); sleep hygiene
Atri, A. Effective Pharmacological Management of Alzheimer’s Disease. Am J Managed Care, 2011.
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General Considerations – evidence-based medicine and opinion
l Promote general physical, social & mental activity and health:
• Good and balanced diet – much to be learned still; best data for MIND Diet
• Keeping mentally engaged with effortful mental activities (not to point of causing stress and frustration)
• Exercise, Exercise, Exercise – emphasize need for commitment to daily (or almost daily) exercise. Explain benefits:
– improved circulation/blood flow to brain à bring nutrients and O2; removing “toxic” proteins that accumulate;
– delivery of growth (neurotrophic) factors important in synaptogenesis and neurorepair;
– shifting balance from stress to relaxation response à to build and repair in face of degeneration and destruction; to fight aging and disease;
– benefits on mood, energy, outlook, and sleep
• Emphasize this as a necessary foundation of treatment plan; and potential “synergy” with pharmacological approaches and genetic resilience factors
Atri, A. Effective Pharmacological Management of Alzheimer’s Disease. Am J Managed Care, 2011.
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Be Proactive to Prevent, Diagnose and Treat Underlying Conditions that Exacerbate
Dementia Symptoms
• Be Proactive: Prevent, detect/diagnose and treat underlying medical and psychiatric/psychological/emotional conditions that can exacerbate dementia symptoms, including:
• dehydration • sleep problems/dysregulation • obstructive sleep apnea • pain • constipation • infections • electrolyte and metabolic derangements • anxiety* • depression* • psychosis* • fear*
* e.g. from loss of independence; lack of understanding, connection or stimulation; boredom
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Helping Caregivers/Care Partners Cope: Educate, Empower and Support l Education regarding disease, illness, strategies,
planning and to develop a support network
l Calm, structured home environment with limited choices and predictable routine
l Common sense problem solving
l Match activities to abilities and preferences – use “just right activities” to avoid under/overstimulation
l Avoid arguing and overwhelming situations
l Driving and home safety
l Care for the Caregivers – empower them to prioritize self-care as a necessary part of a long journey
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Non-pharmacological Interventions & Behavioral Approaches: • Psycho-education including:
• AD dementia in general and effects on cognition, function and behaviors (heterogeneous, dynamic – fluctuations, lower reserve and non-linear) • Dementia stage and care expectations; avoid expectation-reality mismatch and miscommunication
• The “progression and regression model of aging and dementia”
• Learning a “new language” and approach to interact and communicate
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NonPharmacological Interventions and Behavioral Approaches
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l Utilizing strategies such as:
• Stay positive, interact calmly, and be reassuring – practice empathy, reminding yourself that “It’s the disease (it’s not intentional)”
• Redirection to pleasurable activities and environment
à focus on fun and maintaining sense of usefulness/worth • “Talk deliberately, slowly and keep it simple”: Provide only
necessary information in a manner that the patient can now appreciate à in simple language and small chunks and at the appropriate time
• Under certain conditions an consider compassionate “benign
therapeutic fibbing” to avoid unnecessary repeated distress and trauma
• “Never saying No” to “allow the moment to pass” à Don’t
correct, confront, or convince à Let it go and let it pass (unless there is dire immediate safety issue involved)
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• Describe a behavior that challenges; who, what, where, when, and how the behavior occurs
• Investigate thinking like a detective and explore the person with dementia, the caregivers, and environment for possible clues to triggers underlying possible causes of behavior
• Create a prescription in collaboration with your team to help prevent and manage behaviors
• Evaluate and review prescription effectiveness, and modify or restart the process as needed
Courtesy of Dr. Helen Kales
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Sleep-wake dysregulation: evidence-based opinion
l Apathy and lack of stimulation – fragmented and poor quality sleep à vicious cycle of sleeping/napping several times during the day and poor night-time sleep
l Consider non-pharmacological strategies first; educate & support caregivers
l Sleep hygeine: physical, mental, social activity, and stimulation during the day; Avoid PM caffeine (and nicotine)
l Reduce naps to one 1-1.5 hour scheduled nap
l Avoid late and large meals, cool bedroom, no TV late
l Give ChEI in AM
l Consider sleep study (and OSA)
l If refractory: melatonin (2-3 mg one hr before bedtime à if insufficient increase dose 5-6 mg à 9-10 mg)
l In select cases consider low-dose trazadone (25-50 mg), zolpidem, mirtazipine, quetipine, …
Atri, A. Effective Pharmacological Management of Alzheimer’s Disease. Am J Managed Care, 2011.
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Wandering: evidence-based opinion
l Can be very disturbing and dangerous
l Do root cause analysis: is it anxiety, confusion, lack of stimulation and engagement (physical, social, mental), medication side effect?
l Behavioral and environmental strategies à meds unlikely to have favorable risk-benefit profile (due to oversedation, risk of falls)
l Provide engagement and stimulation, and EXERCISE
l Provide safe enclosed area to roam (fenced backyard, corridors w/o access to outside)
l Door locks and alarms that patients cannot disengage easily
l Disguise exits
l Provide medical ID bracelet, GPS, and register w/ safety program (e.g. Alz Assoc Safe Return Program)
Atri, A. Effective Pharmacological Management of Alzheimer’s Disease. Am J Managed Care, 2011.
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Abnormal eating behavior: evidence-based opinion
l Eating changes common – under or overeating, eating inappropriately; craving for sweets, hyperorality, poor impulse control
l Disturbing, dangerous (malnutrition, dehydration)
l Root cause analysis
l Consider that the problem can be caused by medications (wt gain: antipsychotics, TCA, SSRI, mirtazipine, gabapentin, VPA; wt loss: stimulants), endocrine issues (thyroid, diabetes), depression (à treat)
l If compulsive eating: restrict access to food, lock on refrigerators and cabinets, buy small quantities; if refractory consider trial of SSRI or carbamazepine
l Under eating: provide favorite foods (often from childhood), engagement and social eating, small portions (replenished) on large plate, soft music in background
l If refractory: consider mirtazipine (esp. if sleep or depression co-occuring), quetiapine (if severely agitated), megestrol, dronabinol.
Atri, A. Effective Pharmacological Management of Alzheimer’s Disease. Am J Managed Care, 2011.
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Incontinence: evidence-based opinion
l Very challenging
l Root cause analysis
l Consider medical causes (e.g. UTI)
l Restrict caffeine, consider ChEI dose or timing
l Schedule intake and bathroom visits
l Adult diapers
l Bedside commode
l Pelvic floor exercises (need more intact cognition)
l Pessary
l Most medications for incontinence are anticholinergic – if have to may consider long acting trospium
Atri, A. Effective Pharmacological Management of Alzheimer’s Disease. Am J Managed Care, 2011.
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Conclusions
“Where there is no hope, there can be no endeavour” ~ Samuel Johnson
“The journey of a thousand miles begins with one step” ~ Lau Tzu
… the glass is more than half full!
THANK YOU!